When a RAP is returned to provider due to "an incorrect HIPPS was billed on this RAP -- history shows there was an inpatient stay within 14 days of a home health admission"
excerpt from Medicare transmittal [click Preview Attachment to view document] indicates that:
"Whether a beneficiary was a hospital inpatient during the 14 days before the start of an HH PPS episode will be confirmed by searching Medicare claims history for a processed inpatient hospital claim during that period. Under the HH PPS case-mix system, if a beneficiary was in a nursing facility or rehabilitation facility during the 14 days before the start of an episode but was not also a hospital inpatient during that period, the episode will receive a higher case-mix score than if a hospitalization was also present.
Certain HIPPS codes, which represent the HH PPS case-mix group, indicate the presence of a nursing facility or rehabilitation facility discharge within 14 days but no hospitalization during that period. Only when both these conditions are met do HIPPS codes result with “K” or “M” in their fourth position.
Medicare systems will compare incoming RAPs and claims with these HIPPS codes to Medicare claims history for the beneficiary and determine during processing whether an inpatient hospital claim has been received for dates of service within 14 days of the start of care. If an inpatient hospital claim is found, Medicare systems will take action on the RAP or claim. The RAPs will be returned to the provider to alert them to the hospital stay and allow them to correct the HIPPS code. The claims will be automatically adjusted to correct the HIPPS code and will be paid at the correct payment level."
Most likely the nurse that completed the SOC asmt didnt document the hospital stay of the patient that occurred in the 14 days prior to the home health admission date -- you'll need to obtain the add'l info from the patient re: the prior hospital stay, submit a corrected OASIS asmt and submit a corrected RAP